Postpartum Care Plan New Born

EDYTH T.
JAMES DEPARTMENT OF NURSING
NURS 378 Maternal Child and Women’s Health Nursing
POSTPARTUM CARE PLAN
Student Name: Uche Edwards-Shahid Date: 02/20/2019
Student Requirement: Complete all of the information below for each patient cared for during the
clinical rotation day, by consulting the patient record on the assigned unit. The initial information
gathered will be hand written. Please TYPE and submit at the start of the next clinical.
Maternal History:
Age: 28
GTPAL: G1 T 1 P 0 A 0 L1
11001
EDC: 02/10/2019
Blood Type: 0-
0-
Delivery Date: 02/20/2019
Type of Delivery: Virginal Delivery
Weeks' Gestation: 40
40
Significant Labs: N/A
Pregnancy Complications: Low Birth Weight
Complications in Labor None

/Delivery affecting the
neonate:
Length of Labor: 12
First/Second/Third Stage:
NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 1

EDYTH T. JAMES DEPARTMENT OF NURSING
Medications used in Epidural

Labor/Delivery:
Language: English
Significant History: N/A
Postpartum Assessment (BUBBLE HHE):

Breast:
Smooth and full
Uterine fundus/Incision:
None
Bowel:
Bowel sounds in all quadrants
Bladder:
Non -Distended
Lochia:
Slight and light
Episiotomy/Laceration/Tear:
None
Homan’s Sign/Edema: None
Hemorrhoids: None
Emotional stable
PATIENT PHYSICAL ASSESSMENT

Jarvis pages 814 -827, 107-11
General Survey: Mental Status (ABCT:

Appearance/Behavior/Cognition/Thought

process):
Skin: Intact pink Neurologic:
Mouth: Pink mucosa Neck: No lumps,
Heart: S1, S2, RRR Blood Pressure:

110/66
Lungs: Clear Breasts: Smooth, and tender
Peripheral vasculature (Extremities): No edema Pelvic Exam (Stage of Labor): Transition
Abdomen (Leopold’s Maneuvers/Fetal Heart Non-distress

Tones):
HUMAN NEEDS ASSESSMENT
Data:(Assessment findings, test results, Analysis: (What does the data Nursing Dx (NANDA)
drugs) mean…?) (Actual or potential
problem
Oxygenation: Patient is relatively in good Readiness for enhanced
Vital signs: health health management
T___99.0___P_80___R__18_BP___110/66
_
Hgb__14.0__HCT_37___O2Sat__99__
ABGs: PH 7.35 PCO2 55 PO2 80

HCO26

Lung Sounds: clear Oxygen therapy:0
Heart Sounds: Normal
Fluids/Electrolytes: Patient has a balanced Readiness for enhanced

Na:136 K: 4.8 Ca: 8.8 homeostasis nutrition
Intake: 900ml Output:800ml
Nausea/vomiting: None
NPO: None IVs None
Elimination: Patient is relatively in good No risk at this time

BUN: 10 UA Output: none health, ready for nursing her
baby
Urine Character: clear, no odor
Last BM: 02/18/2019
Nutrition: Patient is good in health. Readiness for enhanced

Ht: 5'6 Wt: 150 Every lab result is WNL breastfeeding
Supplements: 0
Blood Glucose: 120 Albumin:

7.0
Hemoglobin: 12.0
Hct:37
NPO: N/A TPN: N/A

Type of diet: Regular Total shift
Intake: Moderate

Data:(Assessment findings, test Analysis: (What does the Nursing Dx (NANDA)

results, drugs) data mean…?) (Actual or potential
problem
Rest/Comfort: Patient needs pain medication Readiness for enhanced
for postpartum discomfort
Pain: Location: ABD Quality: from pushing the baby. The
Cramp body is sore
Severity: 6 Duration:
45min
(on a scale 0-10)
Sleep: No sleep issues. Readiness for enhanced
Normal Hours of Sleep: 8 sleep
Duration: N/A
Mobility: No problem with self-care Readiness for enhanced

Activity Level: Ambulates self and ambulation mobility, selfcare
Activity Tolerance: To and from

Bathroom
Spiritual Integrity: Patient is a dedicated Readiness for enhanced

Religion: Christian, Catholic by Christian catholic spiritual growth
affiliation
Beliefs impacting health status:

None
Affiliation: Patient has support of family Readiness for family
Primary Care Provider/support at dynamics progress/
Home: Yes coping
Family Dynamics: Husband, Mother

in law

Language Spoken: English
Social worker/case manager:
Community resources: N/A
Sexual Integrity: Patient has a healthy family Readiness for enhanced

Development status: N/A relation family relationship
Reproductive organs: Intact
Relationship with significant other:

good
Data:(Assessment findings, test Analysis: (What does the Nursing Dx (NANDA)

results, drugs) data mean…?) (Actual or potential
problem r/t to patient’s
status)
Safety: Patient is ready not be Readiness for discharge
WBC: 10,000 C & S: discharged home. Patient
manage alright
Vital signs: WNL
Wounds/Incisions: None
Hygiene needs: Self care
Perineal laceration/episiotomy:
None
Pain medications: TYLENOL PRN
Lochia: Slight to none
Hemorrhoids: None
Sensation/Perception/Cognition: Patient is cognitively aware Readiness for enhanced

and functioning communication

Orientation: AAOX4
LOC: Intact
Neuro Assessment: Normal
Other Findings: None
Self-esteem: Patient has a healthy self- Readiness for enhanced

Emotional status: Stable awareness and assurance comfort
Mood: Good
Behavior: Appropriate
Appearance: Groomed
Select the TOP THREE human needs and formulate a nursing diagnosis for one. Write
goals and at least FIVE NURSING INTERVENTIONS AND RATIONALES to
accomplish the goal for the nursing diagnosis. (Must cite either Lowdermilk/Perry or
Hockenberry stating “I will ...” or “The student nurse will ...” and must relate to the
Human need and the goal):
1. I will love to get a complete breakfast

2.I will like to go home and sleep in my own bed
3.I will appreciate a good hot cup of coffee
Nursing Outcomes/Goals Nursing Rationales Evaluation (goal

Diagnoses Interventions met or not met?)

Readiness for Make sure there are no Monitor mother Nothing to set Goal is met
enhanced unexpected set backs and baby to back the
comfort make sure they progress made
The PCP needs to set up a are progressing towards
discharge plan as soon to discharge discharge of
possible patient and child
Check up on the lab results
to make sure there are
surprises
Mother and baby are doing

fine
No unexpected set backs

such as complications from
delivery
Medications:
Medications Dose/Brand/Generic Indication Route Frequency Side effects and Nursing
names of use Adverse Effects Considerations
TYLENOL 325 2 tabs PRN Pain Oral PRN Bleeding Must not take more
reducer than PCP prescribed

IV Fluids:
Type of IV Fluids: Rate Frequency Indications of use
None N/A N/A N/A
Treatments and Procedures:

Treatments and Procedures Date & Times Reason for Tests or Procedures
Pain 02/20/2019 Pain management

@9:00
Evaluation of mastery of objectives set for the day (Was the Goal met or unmet? If yes, how?
If not, why not and how can you meet or modify the Goal?):

Yes
Areas for professional growth (the student’s):
Need to pay more attention to the medical terms and usage of proper terminologies for effective
communication and documentation

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EDYTH T.

JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing